Should vital sign criteria be strict in the danger zone vital sign box?
In common usage, when the danger zone vital sign criteria are exceeded, up-triage is “considered” rather than automatic. The experienced triage nurse is called upon to use good clinical judgment in rating the patient’s ESI level. The nurse incorporates information about the vital signs, history, medications, and clinical presentation of the patient in that decisionmaking process. Research is still needed to determine the predictive value of vital signs at triage, and to determine absolute cutoffs for up-triage.
